Empathy: necessary for effective pain management?

Nursing students' empathic communication: Role in recognizing and treating chronic pain patients

OBJECTIVE

A substantial body of research supports what many nurses know from experience: empathy is at the heart of providing quality care. The major objective of this study was to identify unique mechanisms through which higher empathy translates into greater intentions to treat patients in pain employing novel methodology.

METHODS

Using an ecologically-valid scenario methodology, student nurses (N = 156) reviewed the narrative of a patient in chronic pain. They completed standard, valid measures of empathy toward the patient, perception of the patient's pain, and intention to provide pain-relieving treatment. Nursing student's personality traits were assessed and perception of patients' age and sex were experimentally manipulated.

RESULTS

Empathy was associated with higher intention to treat the patient in chronic pain irrespective of patients' age or sex. A moderated-mediation analysis confirmed that nursing students with higher empathy perceived the patient in the scenario as being in greater pain. This was correspondingly associated with higher intention to provide treatment. Nursing students' trait Extraversion was a moderator.

CONCLUSION

Empathy not only improves rapport between patients and providers but is related to intentions to provide pain-relieving treatment.

PRACTICE IMPLICATIONS

The clinical and educational importance of empathy in patient-provider relationships are discussed.

The impact of the social context on the development of secondary hyperalgesia: an experimental study

ABSTRACT

Social support has been shown to reduce pain ratings and physiological responses to acute pain stimuli. Furthermore, this relationship is moderated by adult attachment styles. However, these effects have not been characterized in experimentally induced symptoms of chronic pain, such as secondary hyperalgesia (SH) which is characterized by an increased sensitivity of the skin surrounding an injury. We aimed to examine whether social support by handholding from a romantic partner can attenuate the development of experimentally induced SH. Thirty-seven women, along with their partners, participated in 2 experimental sessions 1 week apart. In both sessions, SH was induced using an electrical stimulation protocol. In the support condition, the partner was seated across from the participant holding the participant's hand during the electrical stimulation, whereas in the alone condition, the participant went through the stimulation alone. Heart rate variability was measured for both the participant as well as the partner before, during, and after the stimulation. We found that the width of the area of hyperalgesia was significantly smaller in the support condition. Attachment styles did not moderate this effect of social support on the area width. Increasing attachment avoidance was associated with both a smaller width of hyperalgesia and a smaller increase in the sensitivity on the stimulated arm. For the first time, we show that social support can attenuate the development of secondary hyperalgesia and that attachment avoidance may be associated with an attenuated development of secondary hyperalgesia.

Evaluating the relationship between pain empathy, knowledge and attitudes among nurses in North China: a cross-sectional study

BACKGROUND

Effective pain management is closely related to nurses' knowledge, attitudes and empathy regarding pain. Nursing educators and managers should understand the relationship between nurses' pain management knowledge, attitudes and empathy level, and take targeted measures accordingly. Currently, there is limited study exploring the relationship between pain empathy and pain knowledge and attitudes among nurses in North China.

OBJECTIVES

The purpose of this study was to investigate the level of nurses' pain management knowledge and attitudes and pain empathy, to analyze the factors influencing pain empathy, and to explore the relationship between these two variables.

DESIGN

This study was a quantitative, descriptive-correlation design.

SETTING AND PARTICIPANTS

The study population was registered nurses in North China, the sample included 177 registered nurses in North China.

METHODS

Data were collected with the "General data questionnaire", "Knowledge and attitudes survey regarding pain" (KASRP) and the "Empathy for pain scale" (EPS) via Wechat mini program "Questionnaire Star".

RESULTS

The 177 registered nurses completed the survey. The averege correct rate for KASRP was (51.94 ± 9.44)%, and none of the respondents achieved a percentage score of >80%. The mean score for pain empathy was (2.78 ± 0.78), the empathy reactions dimension was (2.99 ± 0.77), and the body and mind discomfort dimension was (2.71 ± 0.80). The results of multiple stepwise linear regression showed that whether they had received empathy training, whether they had greater trauma or severe pain and whether they had negative emotions were independent influencing factors for EPS scores. Pearson correlation analysis showed that KASRP scores were positively correlated with EPS scores (r = 0.242, P < 0.05).

CONCLUSIONS

The pain knowledge and attitudes of nurses in North China are far from optimal. Nurses have a relatively low accuracy rate in areas such as medication knowledge, assessment of patient pain based on case studies, and handling PRN prescriptions. Nursing educators and administrators need to design some pain management courses in a targeted manner. Nurses' empathy for pain was at a moderate level. Pain empathy was positively correlated with pain knowledge and attitudes, suggesting that empathy for pain can be developed postnatally.

Virtual Human-Delivered Interviews for Patients With Chronic Pain: Feasibility, Acceptability, and a Pilot Randomized Trial of Standard Medical, Psychosocial, and Educational Interviews

OBJECTIVE

Seminal advances in virtual human (VH) technology have introduced highly interactive, computer-animated VH interviewers. Their utility for aiding in chronic pain care is unknown. We developed three interactive telehealth VH interviews-a standard pain-focused, a psychosocial risk factor, and a pain psychology and neuroscience educational interview. We then conducted a preliminary investigation of their feasibility, acceptability, and efficacy. We also experimentally compared a human and a computer-generated VH voice.

METHODS

Patients ( N = 94, age = 22-78 years) with chronic musculoskeletal pain were randomly assigned to the standard ( n = 31), psychosocial ( n = 34), or educational ( n = 29) VH interview and one of the two VH voices. Acceptability ratings included patient satisfaction and expectations/evaluations of the VH interview. Outcomes assessed at baseline and about 1-month postinterview were pain intensity, interference, emotional distress, pain catastrophizing, and readiness for pain self-management. Linear mixed-effects models were used to test between- and within-condition effects.

RESULTS

Acceptability ratings showed that satisfaction with the VH and telehealth format was generally high, with no condition differences. Study attrition was low ( n = 5). Intent-to-treat-analyses showed that, compared with the standard interview, the psychosocial interview yielded a significantly greater reduction in pain interference ( p = .049, d = 0.43) and a marginally greater reduction in pain intensity ( p = .054, d = 0.36), whereas the educational interview led to a marginally greater yet nonsignificant increase in readiness for change ( p = .095, d = 0.24), as well as several significant improvements within-condition. Results did not differ by VH voice.

CONCLUSIONS

Interactive VH interviewers hold promise for improving chronic pain care, including probing for psychosocial risk factors and providing pain-related education.

A formal evaluation of The Ottawa Hospital Pain Clinic orientation session: A quality improvement project

Background

Chronic pain affects approximately one in every five Canadians and has a substantial impact on psychological well-being, relationships, ability to attend work or school, and overall functioning.The Ottawa Hospital Pain Clinic introduced orientation sessions, with the aim of providing new patients with pain education to help prepare patients for engagement with multimodal pain management strategies. This report summarizes the results of a formative evaluation of the orientation session at The Ottawa Hospital Pain Clinic to determine whether patients perceived the orientation session as beneficial.

Methods

Interviews were conducted, transcribed, and then thematically analyzed to understand patients' perspectives on the orientation session. Coding was done by two team members using the constant comparison analyses method with key ideas, concepts, and patterns identified and compared to identify similarities.

Results

Between September 6 and October 18, 2019, 18 patients attended an orientation session and 12 consented to participation and completed telephone interviews. The six themes identified included (1) feeling of community, (2) participants feeling heard by providers, (3) appreciation of the holistic approach, (4) availability of community resources, (5) barriers to access, and (6) discordant feelings of preparedness for the physician appointment.

Conclusion

Results from this evaluation indicate that the orientation session offered at The Ottawa Hospital Pain Clinic improves chronic pain literacy, reduces feeling of isolation, and instills hope. As such, it appears to be a valuable component of pain clinic programs.

Dealing with Chronic Pain: Tips to Teach Undergraduate Health Sciences Students

Chronic pain is a significant and costly problem all over the world that negatively impacts the quality of life of sufferers. There are clear discrepancies between the prevalence of chronic pain in society and the low priority assigned to educating future physicians about the complexities of pain. This condition also occurs in other undergraduate health science students, although research in this area has not been studied as much as in medical schools. Based on the International Association for the Study of Pain (IASP) Pain Curriculum Outline, a systematic search of the available literature, and the authors' own experiences, we highlight some relevant tips to educate health science trainees in the management of patients with chronic pain. These tips highlight current international recommendations for a comprehensive approach to this prevalent problem in society, which should be learnt during the university training of health professionals.

Evaluating the relationship between empathy, pain knowledge and attitudes among nursing students

BACKGROUND

It is essential for nurses to manage pain effectively. Nurses start to learn about pain while still students. Pain assessment is more effective with knowledge of pain, positive attitude, and empathy. Nurse educators should evaluate nursing students' knowledge and attitudes toward pain management and their relationship with empathy and should revise the curriculum accordingly. No published studies have been found to date where the relationship between nursing students' knowledge and attitudes toward pain and empathy has been investigated.

OBJECTIVES

This aim of this study was to determine the factors affecting pain knowledge and attitudes of nursing students, and to evaluate the relationship between students level of empathy and pain knowledge and attitudes.

DESIGN

This study was a quantitative, descriptive-correlation design.

SETTINGS AND PARTICIPANTS

The study population was 150 students who were studying in the third and senior grades a nursing department in North Cyprus. The sample included 133 nursing students.

METHODS

Data were collected with the 'Student Descriptive Information Form', 'Knowledge and Attitude about Pain' questionnaire, and the "Basic Empathy Scale" (BES). The data were evaluated with descriptive analysis, nonparametric tests, and correlation analysis by using SPSS 20.0 program.

RESULTS

Mean affective and cognitive empathy scores were 30.16 (SD = 4.42) and 29.29 (SD = 2.65), respectively, and the mean score obtained from the Nurses' Knowledge and Attitudes Survey Regarding Pain was 13.50 (SD = 3.22). Furthermore, 91% of the participants stated that the patient is the most accurate judge of the intensity of pain, but only 1.5% of them responded correctly to questions on pharmacological methods of pain therapy. A weakly positive correlation was found between cognitive (r = 0.100, p = 0.252) and affective (r = 0.013, p = 0.881) empathy levels and pain knowledge and attitudes; nevertheless, this was not statistically significant (p > 0.05).

CONCLUSIONS

The study results indicate that curricula regarding pain management should improve the knowledge and attitudes of nursing students toward pain management. Seminars and practical training about how to use empathy in pain management should be planned and clinical practice should be scheduled more frequently.

Empathic Validation in Physician-Patient Communication: An Approach to Conveying Empathy for Problems With Uncertain Solutions

Interest in systematic approaches to improving clinical empathy has increased. However, conceptualizations of empathy are inconsistent and difficult to operationalize. Drawing on video recordings of primary care visits with older adults, I describe one particular communication strategy for conveying empathy-empathic validation. Using conversation analysis, I show that the design of empathic validations and the context in which they are delivered are critical to positive patient responses. Effective empathic validations must (a) demonstrate shared understanding and (b) support the patient's position. Physicians provided empathic validation when there was no medical solution to offer and within this context, for three purposes: (1) normalizing changes in health, (2) acknowledging individual difficulty, and (3) recognizing actions or choices. Empathic validation is a useful approach because it does not rely on patients' ability to create an "empathic opportunity" and has particular relevance for older adults.

Cultivating emergency physician behavioral empathy to improve emergency department care for pain and prescription opioid misuse

Clinical empathy is the ability to understand the patient's experience, communicate that understanding, and act on it. There is evidence that patient and physician benefits are associated with more empathic communications. These include higher patient and physician satisfaction, improved quality of life, and decreased professional burnout for physicians, as well as increased patient compliance with care plans. Empathy appears to decline during medical school, residency training, and early professional emergency medicine practice; however, brief training has the potential to improve behavioral measures of empathy. Improvements in emergency department physician empathy seems especially important in managing patients at elevated risk for opioid-related harm. We describe our conceptual approach to identifying and designing a practice improvement curriculum aimed to cultivate and improve behavioral empathy among practicing emergency physicians. Emergent themes from our preliminary study of interviews, focus groups, and workshops were identified and analyzed for feasibility, sensitivity to change, and potential impact. A conceptual intervention will address the following key categories: patient stigmatization, identification of problematic pain-subtypes, empathic communication skills, interactions with family and friends, and techniques to manage inappropriate patient requests. The primary outcomes will be the changes in behavioral empathy associated with training. An assessment battery was chosen to measure physician psychosocial beliefs, attitudes and behavior, communication skills, and burnout magnitude. Additional outcomes will include opioid prescribing practice, naloxone prescribing, and referrals to addiction treatment. A pilot study will allow an estimation of the intervention impact to help finalize a curriculum suitable for web-based national implementation.

Tell me your dreams and goals: Structuring communication exchanges to improve patient-centered care with chronic pain patients

BACKGROUND

Communicating pain is a difficult endeavor due to the lack of observable pathology, the immeasurable nature of pain, and the presence of comorbid symptoms. While research has shown the value of cure-centered and care-centered communication, it is unclear how chronic pain patients would like to structure pain communication with their providers so that it produces pain disclosure and emotional support. Aim This study examines communication preferences of chronic pain patients including types of questions asked and information received to allow a holistic portrayal of the experience of living with chronic pain.

DESIGN

The research used a quantitative survey that was disseminated via online chronic pain devoted support groups.

PARTICIPANTS

192 respondents took the survey, with women respondents outnumbering men at a 4:1 ratio. Respondents came from 38 states and represented eight countries.

RESULTS

For providers to better understand patients' chronic pain, results indicate they would like providers to inquire about how pain impacts their daily activities, relationships, work responsibilities, and goals and dreams using open-ended questions. These low-stake questions can facilitate emotional disclosure, increase feelings of support, and allow for co-morbid linkages.

CONCLUSION

These inquiries prioritize patients' own subjective knowledge, can deepen the communication exchange between provider and patient, and facilitate pain disclosure. The findings help to deliver patient-centered care, promote rapport, and foster trust between providers and their patients.

Brain activity sustaining the modulation of pain by empathetic comments

Empathetic verbal feedback from others has been shown to alleviate the intensity of experimental pain. To investigate the brain changes associated with this effect, we conducted 3T-fMRI measurements in 30 healthy subjects who received painful thermal stimuli on their left hand while overhearing empathetic, neutral or unempathetic comments, supposedly made by experimenters, via headsets. Only the empathetic comments significantly reduced pain intensity ratings. A whole-brain BOLD analysis revealed that both Empathetic and Unempathetic conditions significantly increased the activation of the right anterior insular and posterior parietal cortices to pain stimuli, while activations in the posterior cingulate cortex and precuneus (PCC/Prec) were significantly stronger during Empathetic compared to Unempathetic condition. BOLD activity increased in the DLPFC in the Empathetic condition and decreased in the PCC/Prec and vmPFC in the Unempathetic condition. In the Empathetic condition only, functional connectivity increased significantly between the vmPFC and the insular cortex. These results suggest that modulation of pain perception by empathetic feedback involves a set of high-order brain regions associated with autobiographical memories and self-awareness, and relies on interactions between such supra-modal structures and key nodes of the pain system.

Living a Life Full of Pain: Older Pain Clinic Patients' Experience of Living With Chronic Low Back Pain

Chronic low back pain (CLBP) is older adults' most common pain complaint and is associated with many physical and psychosocial consequences, which have been quantitatively examined. However, little research has qualitatively examined the experience itself of CLBP in later life. Study objective was to understand older adults' lived CLBP experience. Guided by van Manen's phenomenological method, 21 pain clinic patients aged 66 to 83 completed semistructured interviews. Under the main theme "living a life full of pain," results are reflected in four existential subthemes: (a) Corporeality: The pain is relentless and constantly monitored, (b) Temporality: To live with pain is to live by pacing day and night, (c) Relationality: Pain creates limits that can be tested or obeyed, and (d) Spatiality: Manipulating the space around me to accommodate the pain. Findings improve understanding of the patient experience of late life CLBP and highlights the importance of empathy and patient-centeredness when treating older adults.

Brain-to-brain coupling during handholding is associated with pain reduction

The mechanisms underlying analgesia related to social touch are not clear. While recent research highlights the role of the empathy of the observer to pain relief in the target, the contribution of social interaction to analgesia is unknown. The current study examines brain-to-brain coupling during pain with interpersonal touch and tests the involvement of interbrain synchrony in pain alleviation. Romantic partners were assigned the roles of target (pain receiver) and observer (pain observer) under pain-no-pain and touch-no-touch conditions concurrent with EEG recording. Brain-to-brain coupling in alpha-mu band (8-12 Hz) was estimated by a three-step multilevel analysis procedure based on running window circular correlation coefficient and post hoc power of the findings was calculated using simulations. Our findings indicate that hand-holding during pain administration increases brain-to-brain coupling in a network that mainly involves the central regions of the pain target and the right hemisphere of the pain observer. Moreover, brain-to-brain coupling in this network was found to correlate with analgesia magnitude and observer's empathic accuracy. These findings indicate that brain-to-brain coupling may be involved in touch-related analgesia.

A Review of Current and Emerging Approaches to Pain Management in the Emergency Department

INTRODUCTION

Pain is the most common symptom prompting an emergency department visit and emergency physicians are responsible for managing both acute pain and acute exacerbations of chronic pain resulting from a broad range of illnesses and injuries. The responsibility to treat must be balanced by the duty to limit harm resulting from analgesics. In recent years, opioid-related adverse effects, including overdose and deaths, have increased dramatically in the USA. In response to the US opioid crisis, emergency physicians have broadened their analgesic armamentarium to include a variety of non-opioid approaches. For some of these therapies, sparse evidence exists to support their efficacy for emergency department use. The purpose of this paper is to review historical trends and emerging approaches to emergency department analgesia, with a particular focus on the USA and Canada.

METHODS

We conducted a qualitative review of past and current descriptive studies of emergency department pain practice, as well as clinical trials of emerging pain treatment modalities. The review considers the increasing use of non-opioid and multimodal analgesic therapies, including migraine therapies, regional anesthesia, subdissociative-dose ketamine, nitrous oxide, intravenous lidocaine and gabapentinoids, as well as broad programmatic initiatives promoting the use of non-opioid analgesics and nonpharmacologic interventions.

RESULTS

While migraine therapies, regional anesthesia, nitrous oxide and subdissociative-dose ketamine are supported by a relatively robust evidence base, data supporting the emergency department use of intravenous lidocaine, gabapentinoids and various non-pharmacologic analgesic interventions remain sparse.

CONCLUSION

Additional research on the relative safety and efficacy of non-opioid approaches to emergency department analgesia is needed. Despite a limited research base, it is likely that non-opioid analgesic modalities will be employed with increasing frequency. A new generation of emergency physicians is seeking additional training in pain medicine and increasing dialogue between emergency medicine and pain medicine researchers, educators and clinicians could contribute to better management of emergency department pain.

Exploring the Facets of Empathy and Pain in Clinical Practice: A Review

BACKGROUND

Empathy is an essential element in providing quality patient care. The significance of empathy is even more striking in pain medicine, as chronic pain is notorious for the way it can compromise an individual, leaving him or her isolated and feeling misconceived. This review examines the role of empathy in pain medicine practice.

METHODS

Current and past literature focusing on empathy and pain was searched for in PubMed, Science Direct, MEDLINE (Ovid), MEDLINE (Ebsco), Research Gate, and Google Scholar in July 2015. Search dates were not limited and languages included English only. Search terms were "empathy and pain," "empathy and chronic pain," "physician empathy and pain," "neural mechanisms and empathy," "empathy in clinical practice," "empathy and stigma," and "empathy and medical students". To select relevant publications, the title and abstract of every publication were examined, and when in doubt, the rest of the publication was read.

RESULTS

Four major themes were identified: (1) the neural basis for empathy and pain; (2) the value and challenges of practicing empathy pain medicine; (3) stigma and empathy for pain; and (4) empathy and physician education and training.

CONCLUSION

The review reveals that empathy deserves an unchallenged place in medical care, especially in pain medicine and medical education. It highlights the need to nurture empathy at all levels of professional expertise from medical student to senior doctors.

A mixed methods study of patient-provider communication about opioid analgesics

OBJECTIVE

To describe patient-provider communication about opioid pain medicine and explore how these discussions affect provider attitudes toward patients.

METHODS

We audio-recorded 45 HIV providers and 423 patients in routine outpatient encounters at four sites across the country. Providers completed post-visit questionnaires assessing their attitudes toward patients. We identified discussions about opioid pain management and analyzed them qualitatively. We used logistic regression to assess the association between opioid discussion and providers' attitudes toward patients.

RESULTS

48 encounters (11% of the total sample) contained substantive discussion of opioid-related pain management. Most conversations were initiated by patients (n=28, 58%) and ended by the providers (n=36, 75%). Twelve encounters (25%) contained dialog suggesting a difference of opinion or conflict. Providers more often agreed than disagreed to give the prescription (50% vs. 23%), sometimes reluctantly; in 27% (n=13) of encounters, no decision was made. Fewer than half of providers (n=20, 42%) acknowledged the patient's experience of pain. Providers had a lower odds of positive regard for the patient (adjusted OR=0.51, 95% CI: 0.27-0.95) when opioids were discussed.

CONCLUSIONS

Pain management discussions are common in routine outpatient HIV encounters and providers may regard patients less favorably if opioids are discussed during visits. The sometimes-adversarial nature of these discussions may negatively affect provider attitudes toward patients.

PRACTICE IMPLICATIONS

Empathy and pain acknowledgment are tools that clinicians can use to facilitate productive discussions of pain management.

Partners' empathy increases pain ratings: effects of perceived empathy and attachment style on pain report and display

Pain can be influenced by its social context. We aimed to examine under controlled experimental conditions how empathy from a partner and personal attachment style affect pain report, tolerance, and facial expressions of pain. Fifty-four participants, divided into secure, anxious, and avoidant attachment style groups, underwent a cold pressor task with their partners present. We manipulated how much empathy the participants perceived that their partners had for them. We observed a significant main effect of perceived empathy on pain report, with greater pain reported in the high perceived empathy condition. No such effects were found for pain tolerance or facial display. We also found a significant interaction of empathy with attachment style group, with the avoidant group reporting and displaying less pain than the secure and the anxious groups in the high perceived empathy condition. No such findings were observed in the low empathy condition. These results suggest that empathy from one's partner may influence pain report beyond behavioral reactions. In addition, the amount of pain report and expression that people show in high empathy conditions depends on their attachment style.

Perspective

Believing that one's partner feels high empathy for one's pain may lead individuals to rate the intensity of pain as higher. Individual differences in attachment style moderate this empathy effect.

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The role of empathy and attachment style on pain was studied experimentally.

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Empathy from one's partner may influence pain report and behavioral reactions.

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Perceived high empathy from a partner may lead to higher pain ratings.

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Individual differences in attachment style moderate this empathy effect.

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Individual differences in attachment style also moderate facial display of pain.

Accountability and empathy effects on medical students' clinical judgments in a disability determination context for low back pain

Accountability has been shown to affect clinical judgments among health care providers in several ways. It may increase a provider's motivation for accuracy, leading to more deliberative judgments, or it may enhance biases that evaluators consistently demonstrate with patients with chronic pain. In this study, medical students read a vignette about a hypothetical patient referred for evaluation of severe low back pain by the Office of Vocational Rehabilitation. Accountability to the patient was either weak (consultative 1-time evaluation) or strong (ongoing primary care provision); societal accountability was either weak (evaluation information as secondary source for disability determination) or strong (evaluation information primary to disability determination). Participants then made judgments regarding validity of the patient's presentation, influence of psychosocial factors on the presentation, and patient's level of pain, distress, and disability, and completed an empathy measure. Results showed that empathy had strong associations with symptom validity and severity judgments. With empathy as a covariate, 3 crossover interactions emerged. Judgments of symptom validity were lower when the 2 forms of accountability were inconsistent (ie, one weak and the other strong) than when they were consistent (ie, both weak or both strong). Likewise, judgments of psychosocial factors and pain/distress/disability were higher under consistent accountability conditions than when accountability conditions were inconsistent. This pattern may imply conflict avoidance or self-protection as a motivation for judgments under inconsistent accountability. This study demonstrated that role demands can affect symptom judgments in complex ways, and that empathy may play both direct and moderating roles. Because physicians are the primary gatekeepers regarding disability determination in both consultative and treating roles, accountability may have significant mediating effects on such determinations.

PERSPECTIVE

This study demonstrated that medical student judgments of pain-related symptoms were strongly associated with their levels of empathic concern. Student judgments of symptom validity and psychosocial influences on patient adjustment were differentially affected by their level of accountability to the patient and society in a disability determination process.

The social modulation of pain: others as predictive signals of salience - a systematic review

Several studies in cognitive neuroscience have investigated the cognitive and affective modulation of pain. By contrast, fewer studies have focused on the social modulation of pain, despite a plethora of relevant clinical findings. Here we present the first review of experimental studies addressing how interpersonal factors, such as the presence, behavior, and spatial proximity of an observer, modulate pain. Based on a systematic literature search, we identified 26 studies on experimentally induced pain that manipulated different interpersonal variables and measured behavioral, physiological, and neural pain-related responses. We observed that the modulation of pain by interpersonal factors depended on (1) the degree to which the social partners were active or were perceived by the participants to possess possibility for action; (2) the degree to which participants could perceive the specific intentions of the social partners; (3) the type of pre-existing relationship between the social partner and the person in pain, and lastly, (4) individual differences in relating to others and coping styles. Based on these findings, we propose that the modulation of pain by social factors can be fruitfully understood in relation to a recent predictive coding model, the free energy framework, particularly as applied to interoception and social cognition. Specifically, we argue that interpersonal interactions during pain may function as social, predictive signals of contextual threat or safety and as such influence the salience of noxious stimuli. The perception of such interpersonal interactions may in turn depend on (a) prior beliefs about interpersonal relating and (b) the certainty or precision by which an interpersonal interaction may predict environmental threat or safety.

Re-thinking shared decision-making: context matters

OBJECTIVE

Traditional perspectives on shared decision-making (SDM) focus attention on the point in a clinical encounter where discussion of a treatment decision begins. We argue that SDM is shaped not only by initiation of a treatment decision, but also by the entire clinical encounter, and, even more broadly, by the nature of the patient-provider relationship.

METHOD

The four habits approach to effective clinical communication, a validated and widely used framework for patient-provider communication, was used to understand how SDM is integrally tied to the entire clinical encounter, as well as to the broader patient-provider relationship.

RESULTS

The Four Habits consists of four categories of behaviors: (1) invest in the beginning; (2) elicit the patient's perspective; (3) demonstrate empathy; and (4) invest in the end. We argue that the behaviors included in all four of these categories work together to create and maintain an environment conducive to SDM.

CONCLUSION

SDM cannot be understood in isolation, and future SDM research should reflect the influence that the broader communicative and relational contexts have on decisions.

PRACTICE IMPLICATIONS

SDM training might be more effective if training focused on the broader context of communication and relationships, such as those specified by the Four Habits framework.

Taking into account patients' communication preferences: instrument development and results in chronic back pain patients

OBJECTIVE

The objective is to develop an instrument that measures the extent of matching between patient communication preferences and physician communication behavior and takes various essential aspects of patient-provider communication into consideration. Furthermore we give a description of communication preferences and matching for chronic back pain patients.

METHODS

Using an existing questionnaire for assessing patient communication preferences (named KOPRA), a questionnaire on the communication behavior of physicians (KOVA questionnaire) was developed with identical contents. Combining KOPRA and KOVA items results in preference-matching items. N=703 patients were surveyed.

RESULTS

After item selection all scales of the KOVA questionnaire are unidimensional, reliable, and satisfy the requirements of an item response theory model. The preference-matching scales are also unidimensional and reliable (Cronbach's alpha .87-.91). In addition, there is evidence of the validity of both instruments. Matching between communication preferences and behavior is relatively high overall, but there are some areas with clear discrepancies.

CONCLUSION AND PRACTICE IMPLICATIONS

The preference-matching scales allow areas to be identified in which physicians are not very successful in addressing the communication preferences of patients. With back pain patients, physicians should take particular consideration of the very great need for open communication and information about further treatment.

Perception of pain in others: implication for caregivers

SUMMARY The subjective nature of pain renders its perception in others a challenge for clinicians and informal caregivers responsible for its assessment and relief. Adequate perception of others’ pain relies on different behavioral and neurophysiological mechanisms. Several individual, relational and contextual factors can influence the way the brain reacts to others’ pain and the perception and assessment of this pain. This article focuses on recent neurophysiological and psychological evidence that characterizes these factors, and discusses their potential impact on the perception of others’ pain in a caregiving context. Factors influencing the perception of pain in others are divided into factors related to the self (caregiver), factors related to the other (patient), and factors related to the relationship between those individuals and the context in which the pain is perceived. We propose that the perception of others’ pain plays a crucial role in the treatment provided by clinicians and informal caregivers, and that further research could lead to improving decision-making regarding pain management.

A systematic review of therapeutic alliance, group cohesion, empathy, and goal consensus/collaboration in psychotherapeutic interventions in cancer: Uncommon factors?

The effects of four empirically supported therapeutic relationship factors (therapeutic alliance, empathy, goal consensus/collaboration, and group cohesion) on the outcome of psychotherapeutic interventions conducted with individuals living with cancer were systematically reviewed. PubMed, PsycINFO, and CINAHL were searched from their inception through November 13, 2008. Studies of psychotherapeutic interventions targeted to individuals living with cancer, which also empirically assessed the association between any of these therapeutic relationship factors and psychotherapy outcome were included in the review (8 of 742 papers initially reviewed). Information on study methodology and results were abstracted independently by the authors using a standardized form. Results indicated that therapist-rated rapport and group cohesion were significantly related to positive psychotherapeutic outcomes. No studies examined empathy. The literature on collaboration was mixed, but showed some support for increased collaboration being related to positive therapeutic outcomes. Overall the current literature on the role of therapeutic relationship factors in the context of individuals living with cancer is scant, and much more research is needed to determine the overall contribution of these four relationship elements to the outcomes of psychotherapeutic interventions for individuals living with cancer. Results of such studies could have important clinical and research implications.